The Effect of a Liberal Approach to Glucose Control in Critically Ill Patients with Type 2 Diabetes: A Multicenter, Parallel-Group, Open-Label Randomized Clinical Trial
Authors: Alexis P. Poole, Mark E. Finnis, James Anstey, Rinaldo Bellomo, Shailesh Bihari, Vishwanath Biradar, Sarah Doherty, Glenn Eastwood, Simon Finfer, Craig J. French, Simon Heller, Michael Horowitz, Palash Kar, Peter S. Kruger, Matthew J. Maiden, Johan Mårtensson, Colin J. McArthur, Shay P. McGuinness, Paul J. Secombe, Antony E. Tobin, Andrew A. Udy, Paul J. Young, Adam M. Deane, Rebecca Schultz, Paul Secombe, Magdalena Butler, Keri-Anne Cowdrey, Eileen Gilder, Shay McGuinness, Karina O’Connor, Rachael Parke, Samantha Ryan, Melissa Woolett, Yan Chen, Colin McArthur, Rachael McConnochie, Lynette Newby, Catherine Simmonds, Rinaldo Bellomo, Glenn Eastwood, Leah Peck, Helen Young, Shailesh Bihari, Sharon Comerford, Xia Jin, Samantha Bates, Craig French, Fiona Marshall, Rebecca McEldrew, Rebecca Morgan, Anna Tippett, Miriam Towns, Lynette Morrison, Joanne Sutton, Hayden White, Vishwanath Biradar, Natalie Soar, Meg Harward, Peter Kruger, Josephine Mackay, Jason Meyer, Emma Saylor, Krista Wetzig, Nerissa Brown, Mark Finnis, Kathleen Glasby, Stephanie O’Connor, Alex Poole, Justine Rivett, James Anstey, Deborah Barge, Kathleen Byrne, Annabelle Clancy, Adam Deane, Alana Driscoll, Leanne Barbazza, Jennifer Holmes, Roger Smith, Anthony Tobin, Samantha Bates, Craig French, Fiona Marshall, Rebecca McEldrew, Rebecca Morgan, Anna Tippett, Miriam Towns, Jasmin Board, Emma Martin, Phoebe McCracken, Andrew Udy, Shirley Vallance, Meredith Young, Allison Bone, Michelle Horton, Matthew Maiden, Tania Salerno, Jemma Trickey, Charlie Latimer-Bell, Kirsha Delaney, Deborah Hendry, Cassie Lawrence, Eden Lesona, Alexandra Milington, Leanlove Navarra, Shaanti Olatunji, Raulle Sol Cruz, Rose Sol Cruz, Chelsea Young, Paul Young
Journal: American Journal of Respiratory and Critical Care Medicine (2022)

Rationale: Blood glucose concentrations affect outcomes in critically ill patients, but the optimal target blood glucose range in those with type 2 diabetes is unknown. Objectives: To evaluate the effects of a "liberal" approach to targeted blood glucose range during ICU admission. Methods: This mutlicenter, parallel-group, open-label randomized clinical trial included 419 adult patients with type 2 diabetes expected to be in the ICU on at least three consecutive days. In the intervention group intravenous insulin was commenced at a blood glucose >252 mg/dl and titrated to a target range of 180-252 mg/dl. In the comparator group insulin was commenced at a blood glucose >180 mg/dl and titrated to a target range of 108-180 mg/dl. The primary outcome was incident hypoglycemia (<72 mg/dl). Secondary outcomes included glucose metrics and clinical outcomes. Measurements and Main Results: By Day 28, at least one episode of hypoglycemia occurred in 10 of 210 (5%) patients assigned the intervention and 38 of 209 (18%) patients assigned the comparator (incident rate ratio, 0.21 [95% confidence interval (CI), 0.09 to 0.49]; P < 0.001). Those assigned the intervention had greater blood glucose concentrations (daily mean, minimum, maximum), less glucose variability, and less relative hypoglycemia (P < 0.001 for all comparisons). By Day 90, 62 of 210 (29.5%) in the intervention and 52 of 209 (24.9%) in the comparator group had died (absolute difference, 4.6 percentage points [95% CI, -3.9% to 13.2%]; P = 0.29). Conclusions: A liberal approach to blood glucose targets reduced incident hypoglycemia but did not improve patient-centered outcomes. Clinical trial registered with Australian New Zealand Clinical Trials Registry (ACTRN 12616001135404).